Broadnax Mills, Inc. v. Blue Cross & Blue Shield of Virginia

876 F. Supp. 809, 1995 U.S. Dist. LEXIS 2070, 1995 WL 77940
CourtDistrict Court, E.D. Virginia
DecidedFebruary 21, 1995
DocketCiv. 3:94CV603
StatusPublished
Cited by9 cases

This text of 876 F. Supp. 809 (Broadnax Mills, Inc. v. Blue Cross & Blue Shield of Virginia) is published on Counsel Stack Legal Research, covering District Court, E.D. Virginia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Broadnax Mills, Inc. v. Blue Cross & Blue Shield of Virginia, 876 F. Supp. 809, 1995 U.S. Dist. LEXIS 2070, 1995 WL 77940 (E.D. Va. 1995).

Opinion

ORDER

Upon due consideration, for the reasons stated in the accompanying Memorandum this date filed and deeming it just and proper so to do, it is hereby ADJUDGED and ORDERED as follows: (1) Defendant’s motion to strike Plaintiffs jury demand be and the same is hereby GRANTED; (2) Defendant’s motion to strike Plaintiffs claim for punitive damages be and the same is hereby GRANTED; and (3) Defendant’s motions concerning Counts IV and V and VII through XII of the amended complaint be and the same are DENIED as moot.

MEMORANDUM

MERHIGE, District Judge.

This matter is before the Court on Defendant’s motion to dismiss the following portions of Plaintiffs amended complaint: (1) six state law claims which this Court has previously held to be preempted by the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. (“ERISA”) (Counts VII-XII); (2) Plaintiffs request for a jury trial; (3) Plaintiffs claim for punitive damages; and (4) two counts which were not included in the original complaint and any facts related thereto (Counts IV and V).

I.

In 1978, Plaintiff established a fully insured health benefit plan for its employees. Because Plaintiff was unfamiliar with administering such a plan, it sought advice regarding plan administration and “the availability of, and the need for, insurance to provide ... reasonable protection from liability under the [plan].” Amended Complaint ¶7: Plaintiff engaged Defendant to provide this advice.

The plan was, until August 1, 1989, fully insured by Defendant. On that date, the plan was converted to a self-insured plan upon Plaintiffs enrollment in a modified cost funding (“MCF”) program. Under the MCF program, Plaintiff paid premiums into an operating account managed by Defendant in exchange for the provision of various claims services. The monthly payments made by Plaintiff consisted of funds contributed by both Plaintiff and Plaintiffs employees. Receipts and charges (i.e., claim payments and fees) were recorded by Defendant in the operating account. If, at the termination of the contract, the sum of claims paid plus administrative and other fees exceeded the amount of premiums paid, Plaintiff owed such an amount to Defendant, plus interest; in other words, the MCF program provided no automatic protection against excess liability.

In connection with the MCF program, Plaintiff, during the 1991-92 program year, *812 procured from Defendant an excess risk insurance policy with specific stop loss insurance. This policy limited Plaintiffs liability for claims paid in excess of $60,000.00 per year per participant as Plaintiff was reimbursed for claims exceeding such amount. The policy did not, however, provide any limit on Plaintiffs overall liability for operating account deficits. Amended Complaint 130. Plaintiff contends that Defendant did not advise Plaintiff to procure additional insurance to protect against liability for deficits in the operating account.

Plaintiff followed Defendant’s alleged advice to maintain the MCF program with only specific stop loss insurance for at least three consecutive years. 1 In each year, the agreement did not provide for aggregate stop loss insurance. In the 1992-93 program year, an unusually large number of claims were submitted by plan participants. As a result, the operating account showed a deficit of $420,-063.87 by the end of the 1993-94 program year. According to Plaintiff, the account would have shown a deficit of only $67,765.64 if Defendant had recommended and provided aggregate, stop loss insurance for all program years. Consequently, Plaintiff states that the plan is “entitled to a credit of at least $352,298.23, plus interest.” Amend.Comp. ¶ 56.

Plaintiff also alleges that Defendants did not reveal and pass on to Plaintiff the full amount of provider discounts which Defendant had" negotiated with various health care providers. Specifically, Plaintiff claims that the reported deficit fails to account for these discounts which allegedly amounted to at least $161,921.27, and potentially up to $231,-464.33. 2 Plaintiff states that this amount represents an “undisclosed fee” which Defendant “retained for its own benefit.” Amend. Comp. ¶ 60. In the same vein, Plaintiff charges that Defendant" secretly underpaid certain claims, thus “depriving the plan participants and beneficiaries of their full benefits” under the plan. Id. ¶40.

Next, Plaintiff charges that Defendant failed to explain that, under the MCF program, Plaintiff was liable for all claims “incurred, but not reported” (“IBNR”) prior to the termination of the MCF program, and that Defendant failed to advise Plaintiff that terminal liability limit insurance was available (not to mention required by state law) to protect Plaintiff against potential “excessive liability.” Amend.Comp. ¶ 67. While Defendant eventually agreed to provide an additional stop-loss policy, Plaintiff alleges that such coverage was “inferior” to a terminal liability limit policy, and that the plan will thus be responsible for higher IBNR costs than it would have been had Defendant provided proper advice. Id. ¶73.

Finally, Plaintiff raises allegations related Defendant’s handling of two plan participants’ claims. Plaintiff first charges Defendant with improperly delaying the payment of participant Andrea Talley’s 1992-93 claims until the 1993-94 program year. According to Plaintiff, the result was that such claims were not covered by Talley’s 1992-93 stop loss limit. Moreover, Plaintiff also allegedly lost the benefit of Talley’s 1992-93 stop loss limit when Defendant reported that certain claims were paid in 1993-94 when such claims were actually paid in the 1992-93 year. Plaintiff asserts that the plan was consequently charged approximately $33,000 for these errors. Plaintiff next asserts that Defendant incorrectly stated that a former employee, Delores Edmonds, was eligible for coverage under the plan when, in fact, she had declined COBRA protection. On Defendant’s allegedly erroneous advice, Plaintiff re-enrolled Edmonds. Plaintiff, upon learning that Edmonds was not eligible, directed Defendant not to pay her claims. Defendant purportedly disregarded this instruction and subsequently charged the operating account $39,000.

*813 Plaintiff originally filed a six count motion for judgment in the Circuit Court of Meck-lenberg County on August 1, 1994. The motion for judgment contained state law causes of action including breach of contract, negligence, breach of fiduciary duty, promissory estoppel, negligent misrepresentation and constructive fraud. Defendant filed an answer denying liability and a counterclaim requesting that the Court enjoin Plaintiff to pay the deficit amount. 3

The motion for judgment nowhere mentioned ERISA. Defendant filed a notice of removal on August 18, 1994, basing removal on federal question jurisdiction assertedly created by ERISA. Plaintiff moved to remand the matter to state court on September 19, 1994.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Williams v. Centerra Group, LLC
D. South Carolina, 2022
Perez v. Silva
185 F. Supp. 3d 698 (D. Maryland, 2016)
Wood v. General Dynamics Corp.
157 F. Supp. 3d 428 (M.D. North Carolina, 2016)
Allen v. Scott (In re Scott)
481 B.R. 119 (N.D. Alabama, 2012)
Termini v. Life Insurance Co. of North America
474 F. Supp. 2d 775 (E.D. Virginia, 2007)
Ellis v. Metropolitan Life Insurance
919 F. Supp. 936 (E.D. Virginia, 1996)

Cite This Page — Counsel Stack

Bluebook (online)
876 F. Supp. 809, 1995 U.S. Dist. LEXIS 2070, 1995 WL 77940, Counsel Stack Legal Research, https://law.counselstack.com/opinion/broadnax-mills-inc-v-blue-cross-blue-shield-of-virginia-vaed-1995.